The Centers for Medicare & Medicaid Services (CMS) has issued a Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N) that indicates CMS will cover LDCT as a screening service.
On Feb. 15, 2015, a National Coverage Determination (NCD) was issued stating that coverage was effective immediately, however, CMS did not release critical details such as CPT or HCPC codes or Fee Schedule amounts. Refer to the Decision Memo regarding when these claims should be submitted to CMS.
In the interim, the decision memo provides essential information necessary to the performance of the screening. This article highlights some of the important requirements. However, the memo should be reviewed for additional detail.
Referring physician order required
Unlike other screening services covered by CMS and required to be covered under the Patient Protection and Affordable Care Act, the LDCT screening requires an order from the referring physician (or practitioner). The referring physician is to have a visit with the beneficiary that includes counseling and shared decision making to ensure the patient qualifies for the screening and that the patient makes an informed decision. Some of the criteria for a successful LDCT screening candidate are:
- Age 55 – 77 years;
- Asymptomatic (no signs or symptoms of lung cancer);
- Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
- Current smoker or one who has quit smoking within the last 15 years1
The order from the referring physician or practitioner should indicate that the counseling and shared decision making resulted in the need for the LDCT screening. The medical record must state:
- Beneficiary date of birth;
- Actual pack - year smoking history (number);
- Current smoking status, and for former smokers, the number of years since quitting smoking;
- Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and
- National Provider Identifier (NPI) of the ordering practitioner.2
Physician and facility requirements
As a provider, the Decision Memo places requirements on both the physician reading the study and the imaging facility providing the Technical Component. For the reading physician, besides board certification and documented training in diagnostic radiology, the physician must have had involvement in the supervision and interpretation of at least 300 chest CTs in the past three years, and furnish lung cancer screening with LDCT in a radiology imaging facility that meets the radiology imaging facility eligibility criteria.3
The facility eligibility criteria include a registry and the following requirements:
- Performs LDCT with volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy (milligray) for standard size patients (defined to be 5’ 7” and approximately 155 pounds) with appropriate reductions in CTDIvol for smaller patients and appropriate increases in CTDIvol for larger patients;
- Utilizes a standardized lung nodule identification, classification and reporting system;
- Makes available smoking cessation interventions for current smokers; and
- Collects and submits data to a CMS-approved registry for each LDCT lung cancer screening performed. The data collected and submitted to a CMS-approved registry must include, at minimum, all of the following elements.4
The registry will collect data on the patient, the facility and the results of the study. CMS invites entities to apply as a registry but they currently only list the American College of Radiology as having an approved registry.
Though we do not have all the information we need to code and submit a claim, it is important to underscore that the LDCT screening has been an approved service since February 15, 2015. Therefore, an Advance Beneficiary Notice would be inappropriate for eligible beneficiaries.
It is expected that commercial payers will also cover the LDCT screening with similar criteria. Each payer would have to be surveyed to obtain their requirements and rules for reimbursement.